The CAO will make an eligibility decision within 30 calendar days of the date an individual submits an application. The individual or individual’s representative is the primary source of providing information to establish eligibility for MA LTC. The worker should keep in mind that, because of age, physical or mental disabilities, language difficulties, and other factors, persons may have differing capacities for providing the information needed to establish eligibility.
The individual will always be informed that the help of the CAO worker is available to assist him or her in obtaining the necessary verification needed to determine eligibility for MA LTC. If the CAO cannot make a decision within 30 days, it may extend the period an additional 15 days for a total of 45 days. The CAO will send a letter to the applicant explaining the reason for the delay, when the decision is expected, and that he or she has the right to request a fair hearing.
55 Pa. Code § 125.84 55 Pa. Code § 201.1(2)
NOTE: If an individual is awaiting placement in an LTC facility or HCBS program because a bed or slot is not available, the application may be held pending for 120 days. The 120 days begins on the date the application is submitted. See Section 404.53, Applications Held Pending.
The MA application period can be extended beyond 45 days when the delay is caused by unusual circumstances beyond the CAO’s control. A delay by a third party constitutes unusual circumstances. Other unusual circumstances include a delay by the individual and an administrative emergency beyond the CAO’s control. 42 CFR § 435.911
When the AAA completes the application and advises the individual of the needed verifications, the CAO must have procedures in place to ensure that all information is obtained timely so that an eligibility decision can be made within 30 days of the date the individual submits the application to the AAA.
An applicant may voluntarily withdraw his or her application any time prior to the eligibility decision. The CAO will discuss any misunderstanding of MA LTC requirements or agency procedures to prevent an applicant from unwisely or unnecessarily withdrawing his or her application.
NOTE: If an application is withdrawn because the individual intends to remain in the community, the CAO will determine eligibility for other benefits available to individuals residing in the community.
If the applicant withdraws the application, the CAO will:
1. Have the applicant sign in the Withdrawal section of the application submit a written and signed statement complete and sign a Voluntary Withdrawal Form (PA 1829).
NOTE: The PA 1829 is a tool for documenting an applicant,recipient or authorized representative's request to voluntarily withdraw from both active LTC benefits and/or pending applications. if an individual submits a written statement, then the following must be included in the statement:
List of person(s) in the household and programs they are withdrawing from.
Reason for withdrawal.
individual's signature and date.
2. Record the date in the Withdrawal section of the application.
3. Deny MA LTC, using reason code 063.
4. Record in the case comments the reason for withdrawal if the applicant gave a reason.
5. Reject the application in e-CIS.
6. Send a Notice to Applicant to notify the individual, the individual’s representative, and the LTC service provider, if applicable, that the application was denied due to the withdrawal request. 55 Pa. Code § 125.84
7. Complete the Not Authorized section of the application.
If an individual will be MA LTC eligible upon placement in an LTC facility but there is no bed available, the CAO will notify the individual, in writing, that he or she is eligible pending admission. The application may be held pending for a maximum of 120 days. The 120 days begins with the date of the application.
If an applicant made transfers of assets for less than fair market value (FMV) and placement is not available in an LTC facility, a predetermination cannot be made. The Deficit Reduction Act (DRA) of 2005 changed the start date of a penalty period due to transfer of assets for less than FMV. The start date (of a penalty) occurs when an individual has made an asset transfer, is receiving an institutional level of care, and would be eligible for LTC services except for the penalty period.
The application should be rejected based on the fact that the individual is not currently receiving LTC services. The individual should be advised that he or she may reapply when he or she begins receiving an institutional level of care.
If placement is not available in an LTC facility at the end of the 120 calendar days, the CAO will reject the application and advise the applicant of his or her right to reapply.
If an individual is in need of MA before he or she receives LTC services, the CAO will determine eligibility as for any other MA individual. The CAO may use the original application (paper or online) to determine eligibility for MA.
If the individual is found eligible for MA LTC, the CAO will:
1. Authorize MA LTC, by entering a specific facility or waiver code on the category being opened. This includes individuals determined eligible for a Waiver Program (via notification from the appropriate program office), but for whom a care plan and/or services are not yet available.
2. Using the appropriate reason code, send a Notice to Applicant to notify the applicant of eligibility for MA LTC. Send a copy to the individual, the individual’s representative, and the LTC service provider, if applicable.
3. Complete the Authorized Section of the application.
4. Complete data entry of all information required for the authorization process.
NOTE: An applicant/recipient who transfers a resource without receiving FMV may receive regular MA but is ineligible for a payment of LTC services for a specified number of days. Each transfer of assets for less than FMV must be entered separately into CIS. On applications, this period of ineligibility is computed by CIS and the appropriate codes are automatically entered into the TPL system to alert PROMISe of the type of payments permitted.
Example: Mr. S. enters an LTC facility on March 19 and applies for MA LTC. Mr. S. transferred $55,000 to his son and daughter in February. The penalty period will be calculated using the average daily private pay rate in effect at the time the case is processed. eCIS will then determine eligibility for regular MA. If eligible, the worker would authorize MA LTC effective March 19. CIS would complete a 903Q TPL entry to alert PROMISe of the period of ineligibility for payment of LTC services.
The CAO will determine eligibility for payment of LTC services by first determining if the individual is eligible for MA LTC
(STEP 1).
If the individual is eligible for MA LTC, the CAO will determine if the individual is eligible to receive a payment toward the cost of his or her LTC services
(STEP 2)
See Chapter 468, Eligibility and Payment. An individual is ineligible for an LTC services payment if his or her net income after allowable deductions exceeds the MA LTC payment rate multiplied by the total number of days of LTC facility services received in the month.
If the individual is eligible for MA LTC in STEP 1 but not eligible for an LTC services payment in STEP 2, the CAO will:
1. Authorize MA using the appropriate reason code.
2. Explain the services covered by the MA program.
3. Complete the Authorized Section of the application.
4. Send a Notice to Applicant to notify the applicant of eligibility for MA. The notice will advise the applicant that the LTC facility may not charge more than the MA payment rate. Send a copy to the AAA, the individual, the individual’s representative, and the LTC facility.
5. Complete data entry of all information required for the authorization process.
If the individual is determined not eligible for MA LTC in STEP 1, the CAO will:
1. Deny MA LTC, using a reason code appropriate to the reason for ineligibility.
2. Record the appropriate information and reason for denial in the case record.
3. Send a Notice to Applicant to notify the applicant of ineligibility. Send a copy to the AAA, the individual, the individual’s representative, and the LTC service provider, if applicable.
4. Complete the Not Authorized section of the application.
5. Complete data entry of all information required to deny the application in CIS.
The applicant is responsible, to the extent that the applicant is able, for providing the required verification to establish eligibility.
The CAO will assist the applicant, if necessary, in obtaining the required verification or establish a reasonable plan with the applicant to obtain the verification.
If the applicant fails to cooperate in providing the necessary verification, the CAO will: 55 Pa. Code § 125.84
1. Deny MA LTC, using reason code 042 for the denial.
2. Send a notice that includes:
What information was not provided or what action was not taken; and
The regulation that required this information or action.
3. Complete the Not Authorized Section of the application.
4. Complete data entry of all information required to deny the application.
NOTE: A new application (paper or online) is not required when an application is denied for failure to cooperate in providing the necessary verification and the person provides the required information within 60 days of the application denial date. 42 CFR § 435.911
Example: Mrs. B. is admitted to an LTC facility on January 5. An application for MA LTC is signed and dated on February 10 at the LTC facility. The LTC facility is requesting an effective date of January 5 for MA LTC. The application is received and date stamped in the CAO on March 1. On March 15 the CAO caseworker processes the application and notifies Mrs. B.’s representative that additional information is needed to authorize MA LTC by March 30. On April 5, the caseworker denies the application for failure to provide information and sends the appropriate notice. On April 25, Mrs. B.’s representative contacts the CAO and provides the required information. The caseworker authorizes MA LTC effective January 5 using the application received in the CAO on March 1.
Updated February 7, 2017, Replacing June 14, 2016